- September 8, 2023
- Posted by: spiderman
- Category: Cardiology Billing
Prior authorization requirements for cardiology procedures have been increasing over the years, resulting in serious implications for patients, cardiologists, and healthcare providers. For patients, negative outcomes of increasing precertification requirements include delayed care, increased out-of-pocket expenses and deterioration of health. Whereas, for healthcare organizations, increase in PA requirements may result in lower reimbursements, longer payment cycles, loss of revenue, and negative patient experience. These complications are adding to the existing economical, operational, and inflationary challenges that healthcare organizations are trying to overcome.
Therefore, to aid decision-makers at healthcare organizations, we shall discuss the most common factors behind denial of PA requests and highlight how professional RCM services can fill in the gap to reduce the utilization management (UM) burden. Furthermore, this article will also shed light on factors to consider when outsourcing prior auth operations for cardiology procedures.
5 Studies Highlighting Serious Problems with Prior Authorization (cardiology procedures)
♦A study published in the American Heart Association’s journal, Circulation, titled, ‘Cardiovascular Quality and Outcomes’ found that “precertification requirements have increased by 30% for cardiac procedures between 2014 and 2018, with the average time to get approval growing by 10% during the same period”.
♦ A survey titled, ‘The Physician and Administrator-Reported Cost of Drug Utilization Management to Physician Practices: A Cross-Sectional Survey’, by the journal, PharmacoEconomics, found that “an average physician practice spends $853 every year on pre-approval related tasks”. The survey also highlighted that “90% of physicians reported that prior auth delays access to care”.
♦ A study published in Health Affairs reported that “physicians spend 16.4 hours every week on average on prior auth-related tasks including form fill-ups, request submission, and denial management”.
♦ A 2021 report published in the journal, Healthcare Financial Management, found that “medical practices that outsourced at least one non-clinical administrative function had a 10% higher net income compared to the practices that did not outsource”.
♦ A study published in 2022 by the Medical Group Management Association, reported that “practices that outsourced their precertification operations experienced a median net income increase of 5%, with significant reduction in denials and time spent on PA”.
Most common cardiology procedures with low prior authorization approval rates
According to a study published in the Journal of the American College of Cardiology, the most common cardiology procedures with low prior authorization approval rates are:
- Transcatheter aortic valve replacement (TAVR)
- Percutaneous coronary intervention (PCI)
- Implantable cardioverter defibrillator (ICD)
- Heart transplantation
- Heart valve surgery
- Carotid artery stenting
- Coronary artery bypass graft (CABG)
- Electrophysiology (EP) procedures
Factors responsible for denial of prior authorization requests for cardiology procedures
The pressure of increasing prior auth requirements is making the current economic and operational challenges worse for healthcare organizations. To ease these pressures and effectively deal with the problem of prior-authorization denial for cardiology procedures, it is crucial to understand the most common factors that insurers cite to deny approval.
- Lack of medical necessity.
- Experimental or investigational nature of the procedure.
- Patient’s conditions don’t meet criteria for the procedure.
- Patient’s health plan does not cover the procedure.
- Incorrect submission of prior auth requests.
How cardiology-specific prior authorization services help overcome these challenges
Due to the nature of their work, reputed healthcare RCM companies have to follow industry best practices. From leveraging automation tools to hiring certified cardiology prior authorization specialists, these companies leave no stone unturned in ensuring optimization of prior auth operations for their clients.
By strictly following standard operating procedures and industry best practices, revenue cycle management companies enable healthcare organizations to overcome challenges posed by increasing prior auth requirements by offering the following benefits:
- Reduction in precertification waiting time.
- Reduction in delays to care.
- Significantly lower administrative burden.
- Lower operational & labor cost.
- Higher net income.
- Fewer denials.
- Shorter payment cycle.
Factors to consider when outsourcing cardiology prior authorization services
Selecting the right cardiology prior authorization services partner is as important as the decision to outsource prior auth functions. If not done properly, outsourcing operations can do more damage than good. Hence, it is advisable to perform due diligence and follow necessary steps before outsourcing PA operations. A few factors that cardiologists and healthcare providers should consider when outsourcing precertification operations are as follows:
♦ Expertise and experience of the RCM company in securing prior approval for different cardiology procedures including Transcatheter Aortic Valve Replacement (TAVR), cardiac-periphery interventions, PCI, and other relevant procedures.
♦Experience in securing approvals from various insurers including UnitedHealthcare (UHC), Aetna, Humana, BCBS, WellPoint, Anthem, and government plans including Medicare and Medicaid.
- Experience in handling electronic prior authorization (ePA).
- Utilization of automation tools and technology solutions.
- Real-time eligibility checks.
- Detailed overview of the RCM company’s prior auth workflow to identify gaps.
- Certification of prior auth specialists.
- Customizable and extensive reporting.
- Adherence to industry best practices.
- Cost per FTE.
- Productivity of each FTE.
- Dedicated account manager.
- First-pass rate.
- Regular audit of operational functions.
- Client testimonials
For queries on comprehensive prior authorization services for cardiology procedures, it is best to consult a reputed healthcare revenue cycle management company with rich industry experience and proven expertise.